The third year and fourth years of medical school were known as the clinical years. We were entering the hospitals which would now serve as our classrooms. It began on day one with donning the uniform we all had to wear. It consisted of a white tunic which many of you might remember from watching the TV show Ben Casey, white pants, and white buck shoes all of which were the trademarks of how a physician in training looks. My future wife claims this is what really attracted her to me. So much for my magnetic personality! We also carried our black bag of instruments and the stethoscopes which would dangle around our necks. This year would consist of rotating through all the specialties of medicine. I can still remember how excited I was to finally put on that uniform. It would transform us instantly into a doctor in training instead of the medical student we had been for the last 2 years. We were about to learn what it was like to diagnose a patient’s problem, learn in detail various diseases and then propose how we were going to care for and treat them so that they would become well again.
But before we could actually do that, we had to learn from the bottom up how to perform what was known as scut work. That involved performing all the detailed tasks like learning to draw blood samples, starting intravenous infusions, checking urine samples, and performing tests on stool specimens. We had to learn how to perform all these basic tests so we could understand how they were done, what results they would give, and what were their limitations and sources of error. We performed these tests day in and day out, often in the middle of the night, and on weekends and holidays. This was the start of our exposure to the fact that being a doctor can and often is a 24 hour a day, 7 days a week job. We were about to understand what our future lives would be like. The patient comes first and all else is secondary. There is a hierarchy in training hospitals that begins with the lowly medical student and progresses up to interns, residents, fellows, instructors, associate professors, and finally the professors in that order. So we were at the bottom rung of this food chain and were constantly reminded of it. But, as medical students, we were expected to do all the scut work that supplied the information on to the next person above us who in turn would pass it on to the person above them. And if you did not do the work or, worse, did not do it correctly, boy would you hear about it! If you made the person above you look bad, your life was definitely about to become miserable. So everything began with the medical student and ended with them also if you did not do your work properly. Hours and hours were spent learning how to interview the patients that were assigned to your team. Detailed histories were taken and physical exams were performed and then written up on the proverbial chart which held the entire record of the patient’s hospitalization. The lab tests were organized, analyzed, and then everything had to be memorized.
We also learned what was involved with making rounds. That word explains the way a team of physicians would go from patient to patient daily to review the status of every patient they were responsible for. Rounds were made by the entire team of physicians and occasionally grand rounds were made with one of the professors. Each professor would have a case presented to him by a medical student and then the fun began, not for you but for them. Questions were asked of you and you had better have the right answers or you would be humiliated in front of everyone. You were condescendingly called doctor and then reamed out unmercifully. If you were picked to present the case, you could plan on not sleeping much for the next few days while you reviewed every detail about that patient and the disease he or she suffered from. Most professors operated under the philosophy of asking questions until you did not have any more answers. Grades were basically determined by how many questions they would have to ask to find out the extent of your knowledge of that patient and his or her disease and treatment. So while it sounds like it was a lot of work, it was but it was so interesting that you could put up with a lot of the nonsense that went along with it. And believe me there was a lot of nonsense, but it was all part of the process that all physicians have gone through. So let’s begin our rotation through all the medical specialties. You will get a flavor of what each specialty is like and I hope you will be amused, saddened, or just enjoy some of the stories I will relay as much as I had.
The General Medicine rotation was the longest and most difficult of all the rotations. I can remember having dreams about what it would be like before I started and, believe me, it was worse than most of my dreams or sometimes nightmares. That rotation was located at Newark City Hospital later known as the Martland Medical Center. It was right in the downtown area of Newark, New Jersey, and it was where the indigent population of the city was cared for. When the medical school moved there from Jersey City, it immediately improved the quality of medical care for the local residents, or so I was told. It was one of the dirtiest places I have ever worked in and probably the most dangerous. It was right in the middle of the ghetto area and the amount of crime was very high. Drugs were quite prevalent and so was the inevitable crime that went along with it. Most people did not have the money or insurance to see a private physician, so the hospital and its clinics were where the majority of the local people received their medical care. Having been raised in a middle-class suburban environment, I was shocked from day one with what I saw every day. Muggings, knifings, gun-shot wounds were the way we would begin to be exposed to medical care in a big city hospital. But it was where I would see and learn so much that it made it a rewarding experience but nonetheless shocking and sad that it was how many people had to live and more importantly try to survive. Now that you can appreciate the setting we will enter the hospital for the first time. The timing is the late ‘60’s just before the racial riots that would rock the nation and that city in particular.
The medical rotation would begin by working on the wards of the hospital caring for the indigent in-patients. It was where we began to understand different diseases like hypertension, diabetes, heart disease and various types of cancer. The textbook of Internal Medicine contained thousands of diseases and explained how to diagnose, understand, and treat patients suffering from those conditions. Also it was not unusual for one of us to become convinced that we had whatever disease we were studying. As I said we began on what was known as the wards. A ward is basically a large single room with maybe 20 or more patients, each in their own bed and separated only from the next patient by a curtain. They were the patients who could not afford to pay for their medical care and so it was supplied to them free by the city and state. It was a very impersonal place with a mixture of smells and fluids that emanated from their bodies. I will never forget the first time I walked onto a ward, took a deep breath and immediately thought I would be sick. But with time we would become immune to it. It reminded me of the horrible smell of first year anatomy lab. We were introduced to the head nurse, who was a middle-aged black woman who welcomed us to “HER WARD”. She was not a real friendly person and she made it quite clear that we would follow her rules to the letter or else we would be reported. She had her hands full with her nurses who cared for the patients and it was evident immediately that she would tolerate us, but we were really just in her way. She would also make it very clear that we were not to abuse or harass her nurses in any way. So here was this place that looked awful, smelled terrible, and we were really not welcome to be there. What a great environment to begin learning to become a physician! It really was but, at the time, it seemed barbaric. Thank God my parents never had to see how I was being educated with their hard-earned money.
We were divided into care teams and each consisted of about four or five students, an intern, and a resident physician. Interns were doctors who had just completed medical school and were being paid to care for patients while receiving more advanced training and responsibility. The salary, as you will see later on, was one that you could barely survive on. At that time internships were required for one year before we could get licenses to practice medicine. Those who did not want to be family doctors went on to become residents in a particular field of medicine. Resident physicians were one more step above interns and received slightly more but still poor salaries. Residency programs were quite competitive to get into and to stay in depending on the program and the particular hospital or medical center. Interns were abused on a level almost as bad as the medical students and the only difference is they were getting paid for the abuse. Medical students were not essential to the care of those patients and some of them liked us and some of them hated us. Many interns went to medical school in foreign countries and occasionally there was quite a language barrier between us. Patients who liked us were grateful they were receiving a little tender loving care and even looked upon us as their advocates. They would come to us with their problems within the hospital or with the other doctors. Those that disliked us usually revolved around the fact that they were there for awhile or had multiple admissions in which they would be telling us their history for the hundredth time. Patients who had been in the hospital for many admissions also would love to play little games with the medical students. They knew their diseases very well from listening to their cases being discussed on daily rounds so many times that they knew all the terms of their illnesses by heart. When I would come around to admit them often they would just give me their diagnosis to get rid of me. One time I was told “look doc I have Mitral Valve Stenosis, which is a narrowing of that valve in my heart caused by the fact that I had Rheumatic Fever when I was young, now go away.” Not only was I getting humiliated by the professors, I was also shocked that my patients knew more about their problems than I did. Because many of those patients were poorly educated they had a language unto themselves from the ghetto. One lady told me she had smiling mighty Jesus when she was young. What in the heck was that, I asked myself? My intern would later explain to me that was the way some patients referred to spinal meningitis and as hard as I looked I would not find smiling mighty Jesus in the textbook. Another amusing term used by patients was I have fireballs of the eucharist. That stood for fibroid tumors of the uterus. Over time we came to understand the slang words and phrases those people had for many of their diseases and I still chuckle over some of them to this day.
I was beginning, after a while, to develop quite a compassion for those indigent patients. Many were in and out of the hospital like a revolving door because when they went home they didn’t have any money to pay for their medicine and would wind up back in the hospital after a short period of time. Some of them I began to know by their first names they had been in so frequently. Part of our job was to try and convince them to enroll in the outpatient clinics to continue their care once they were discharged from the hospital. There they could get their medicine for free. We were also responsible for educating new patients about their diseases like diabetes. Besides doing the admission history and physical exam (otherwise known as the H & P) we drew blood samples and started intravenous fluid therapy. I started so many IVs I bet I could have done it in my sleep and, many times, I think I did. On occasion I fell asleep at night with my head buried in a chart while writing up an H & P. Depending on the particular disease those patients had we would also learn a lot of procedures involved with diagnosing and treating it. So, one by one, we learned disease after disease in great detail supplemented by reading the textbooks. It was at this time that many of us began to suffer from what was known as Medicalschoolitis. It is a condition as I mentioned before in which we thought we had every disease we were studying. We learned how to do procedures like spinal taps, paracentesis, inserting central lines, inserting and removing foley catheters, and biopsing various organs like the liver or lung. We learned by the old medical adage “see one, do one, teach one.” Because there were many more patients than students, there was no shortage of work and procedures to do. Repetition is a great way to learn and I had done many things by the end of the rotation that I never thought I would do until much later in my training. That was the great advantage of working in a big city hospital.
Most of the interns and residents were really very bright and I learned a lot from them. We spent many hours together and, in our spare time, which was infrequent, we developed some good friendships. Many were foreign doctors who came to this country to further their education and it must have been very difficult to learn another language and totally different culture. We exchange thoughts about religion, politics, and our cultural differences. It was obvious that they missed their native countries very much and they yearned to return home after completing their training. They all loved to talk about their homelands and I learned quite a bit about countries like Korea, China, India and the Philippines. They all were quite impressed by the level of medical care that is given in this country. In many of their homelands, medical care was either nonexistent for the poor and barely available to the wealthy. They were amazed when they first realized that many diseases were either preventable or treatable whereas, in their countries, many diseases were fatal. Many came from fairly wealthy families otherwise they could not get their education and be able to come to America to further their training. They all convinced us how lucky we are to have such advanced medical care available in the United States. It was quite interesting to hear what medical care was like in their countries. Most spoke English very well, certainly far better than I would have been able to do if our roles were reversed and I was training in their country. I often thought about how I would've done in Italy. I really don't think I would have done well at all.
One morning I was told that in a few days I was going to be presenting a case for Grand Rounds with one of the professors. We never knew who it was going to be so the stress factor just mounted until that person arrived on the ward. I did my case review as well as I could and hoped for the best. I had notes on index cards in my pocket with various facts, lab results, etc. just in case my mind would suddenly go blank. I had seen several of my classmates go through the ritual and, depending on the individual and the professor, it could be a valuable learning experience or an absolute nightmare. There were certain professors who were feared because they had reputations for making medical students look like idiots. Not that it was hard to do because our level of knowledge and theirs was not even in the same ballpark. If any one of them wanted to put someone down, it was not hard and it did not take long. I slept rather poorly the night before and I arrived on the ward nice and early at 4:30 AM to prepare. I was the one for that day who was about to be offered up to the gods of medicine. While I reviewed my notes, I wondered which doctor I was going to get and the tension mounted the more I thought about it. It was like having the lead role in a play and everyone's eyes were going to be on me. I was worried that when I gave an answer my lips would move but nothing would come out of my mouth. When 10 o'clock rounds time rolled around, I was just short of being a basket case. I would be lucky if I could remember my name, let alone all the information I had crammed into my brain. Naturally on to the ward came one of the most feared professors in the Department of Medicine. How could I be so lucky? I had drawn the ultimate short straw and it was time for the execution to begin.
The professor assigned for me that day was an internationally known researcher in the field of liver disease. He was a relatively short African-American with an ego a mile-long. He was always pleasant but could cut you apart so well with his tongue you didn't know you were bleeding until hours later. He walked towards me and introduced himself and said “what's your name doctor?” I hate that sarcastic remark even to this day. I instinctively looked at my notes and blurted out my name Pieter Ketelaar, sir. The sarcasm continued when he asked if I really needed my notes to know who I was. I got the feeling this was not going to be pretty and I was ready to be sacrificed. It only remained for how long and how badly I would be humiliated. I had remembered going to one of his lectures in which he started out by saying “it is my opinion, therefore your belief, that the liver is the most important organ of the body." Fortunately, my patient had the healthiest liver on the ward so I took a deep breath and hoped I could dazzle him with other information about my patient. So he began "tell us about your patient, sonny." I rattled off the patient's history and pertinent physical findings along with assorted laboratory reports and hoped that the longer I talked the less time he had for questions for me. He listened attentively and then he started in on me. "Well, tell me doctor, what differential diagnoses do you have for this patient based on the information you have just given us?" Differential diagnosis was a phrase which was new to us, but we would come to use it in evaluating patients the rest of our lives. It simply meant what diseases could possibly fit with the history, physical findings, and laboratory results of each patient. It is a mental tool used to develop the proper thought processes of evaluating all our patients. I was ready for that one and gave a comprehensive list of possible diseases which my patient could have, but I did know the one he had very well. But, of course, the questions he had for me related to the more rare conditions that I knew little about other than their names. He was being kind but clearly I was being shown who was the boss. Finally we came down to the medications which we were giving this patient. "Can you tell me how this medication works and how does the body get rid of it?" Yikes, he had set me up perfectly. Here comes the liver into our discussion and he proceeded to give a lecture to me and the rest of the team about how the liver converts medications into harmless byproducts that are then excreted from the body. While I stood sweating and being torn apart limb from limb, one of the interns started smiling and the professor noticed it. Suddenly, I was no longer the main target and he proceeded to literally destroy him. While he demanded much from his medical students, even more was expected from the interns. After he was finished and I mean finished with the intern, it was back to me. Well, it went on for about two hours altogether and, by the end, I thought maybe I would like to be a bus driver instead of a doctor. As a child I had always played on my bike like I was a bus driver and thought maybe that's what I might like to become when I grew up. Now it looked like I had made a pretty bad decision not to become one. As he started to walk away he turned back to me and said "good job, sonny." Well, I guess that meant that I had survived the attack but as I was lying in a pool of my own blood it sure didn't feel like it. Our resident came over and said "good job, I've rarely seen him say anything complementary like that." So I went from 1 minute thinking that the shark had completely torn me apart and left me to die, to hey, I must've done okay. Better yet, I'm better than okay I just got a compliment from The Man. My future encounters with him were all pretty similar. First impressions with him must've been important because I was never beat upon again. I realized that he could bite hard but, if you knew the basics, you were okay by him. Many years after I had graduated and was in private practice he went on to found a large center for liver research and treatment at the medical school which was named after the major contributor, Sammy Davis, Jr. I was there for the dedication of the building and I got a brief moment to thank him for all he had taught me. He replied as I expected with a smile and "you're welcome, sonny." Dr. Leavy was truly a giant in medicine and it was a privilege to have known, let alone be taught by, him. I was saddened recently to hear of his death but I fondly remember a wise, knowledgeable and kind man. The world of medicine will deeply miss this outstanding physician.
The next area we rotated through was the medical emergency room. Anyone who has ever been to an emergency room knows there are always a couple of givens: first the wait will be long and, second, you never know what will walk, roll or be wheeled in at any moment day or night. ERs, as they are known to physicians, can be dead quiet 1 minute and all hell can break loose the next.The personnel from doctors to nurses to ancillary staff are all geared to the fact that they must be able to switch into high gear quickly. Lives can be lost or saved in minutes. When people think of an ER, most associate it with accidents, broken bones, asthma, and heart attacks. While they comprise the majority of visits, it can really vary from a cold to a major trauma and everything in between. It was a great place to work because it sharpened your skills to the point where I knew I could handle just about anything that would come through the door. Or so I thought. There also is a big difference between a community hospital ER and a teaching hospital intercity one. In fact, there are huge differences. My comments now will be related to the latter. I will touch on community hospital ERs when we get into my private practice. The ER was a great rotation always for the medical students because we got to see and do a lot. Because of the size of the hospital and the large city it served, our ER was divided into three separate departments: medical, surgical, and pediatric.
Inner-city hospitals functioned quite differently from urban hospitals because of the types of patients they care for. Minority and low socioeconomic areas have patients use ERs as others would use their private physician. But if you do not have a private physician or the money to pay for one, such patients are only left with one alternative and that is the ER. This leads to an expensive allotment of care, but it is all these patients know. To them when you are sick, you go to the emergency room. As a consequence, many ER visits in a city hospital involve such basic care like visits for colds, sore throats, and minor allergies. So while taking care of those conditions got routine very quickly, we were still practicing medicine for the first time and it made us all feel important and needed. But as time went on, we saw more than our share of things like myocardial infarctions, overdoses, strokes, lacerations, asthma attacks, and hypertension. On the weekends, visits to the ER would drastically increase and the interns and residents would say it was a result of the meeting of the local knife and gun clubs. When welfare checks were delivered, the drinking and fights would break out and, naturally, we would see the victims. Most of those cases would wind up in the surgical emergency room, but we would also get a fair number of the minor cases. It was there that I was taught how to suture lacerations and I must say I enjoyed sewing up wounds right from the beginning. Of course, because a lot of these patients had been drinking, it sometimes was a challenge to suture a moving target. And learning how to restrain the patient was an art that we practiced frequently. Sometimes on the real violent customers that would involve very ingenious methods to make them hold still while their wounds were being repaired. But we did what we had to do to get the job done, sober them up and discharge them until our next meeting. It was also the first time I saw and got to care for patients who had OD’d on drugs. Heroin was the predominant drug of choice back then and the most common way they presented to the ER was unconscious. Most came alone so there was no history, we just had to suspect it and treat it accordingly, when they woke up we were able to fill in the blanks. Sadly, we would see some of these patients on a regular basis with the same problem. Many times some of them did not make it and it was difficult to see them end their lives in such a needless fashion. Even worse many were just teenagers. They also could not be trusted because they became very good liars to cover up their vices. It also was a challenge to find a vein that had not been destroyed by their intervenous drug abuse. Some of them, if they were conscious, would tell us where to find a good one. We regularly also saw patients paralyzed from strokes because undiagnosed high blood pressure is very common problem in African-Americans. Because there are few symptoms of hypertension until something serious results, we usually had to deal with the effects of the stroke along with blood pressures that were out of control. It was good training for me but sad because many of these problems could have been prevented. So, after a two-month rotation, we had a good exposure to emergency medicine and I sort of liked the unpredictability that it brought along with it. I was learning a lot and every day was an adventure.
We then turned our attention to pediatrics. That turned out to be, for me, one of the most rewarding and yet one of the saddest periods in my training. There is nothing more rewarding than restoring the health of a sick child and there is nothing sadder than the loss of one. I was about to experience both as we launched into the study of the normal and ill child. Children are such innocent beings and it is really hard for a physician to divorce himself from that to objectively care for them. I learned very early on in my rotation that I had a lot of trouble doing it and, as a result, it would not ultimately become my specialty of practice. From learning all the normal development of a child, to the timing of all the different vaccinations, to all the illnesses that could possibly affect them was a daunting task, but one that we were all anxious to do. We would staff different clinics to provide care for these children and it was an important part of the care that the medical school brought to the community. Without it, many of those children would have not had a chance to see a physician and many of us were tremendously touched by the opportunity. Caring for children can be extremely difficult because they are not always able to communicate their problems. Much like veterinarian medicine, you must be able to find out their problems without communicating with them. That is where you begin to develop such important skills as observation, smell, and touch. Watching how thedifferent pediatricians were able to do that was quite an experience and one that requires many unique talents. You could see the joy in their faces as the clinicians cared for those little people. But we would be taught over and over again that they are not just small adults. They are unique human beings with their own special needs. Some of our professors were the most kind and caring physicians I have ever known and it was a pleasure and a privilege to see them work their special magic in caring for their patients. And finally it was during that rotation that I would experience for the first time the tremendous sadness of losing a patient.
One of the real joys of pediatrics, at least for me, was working in the newborn nursery. Newborns present a very special challenge to care for and, fortunately, most are born healthy. Back in those days we did not have the subspecialty of neonatology (which is the care of high-risk newborns). That was to come along several years later. The development of newborn intensive care units, or NICUs as they are now known, was to become a particularly large advancement in medicine. Premature delivery up until then was almost a death sentence for a newborn. Now babies as early as 20 to 22 weeks at least have a fighting chance of survival thanks to those special places and physicians. One of the hardest things to deal with was seeing babies born with birth defects. Most people expect to have healthy normal babies, but it is a fact of life that that is not always the case. Nature is not always perfect and when children with major birth defects are born it is a tragedy and quite a shock for their parents. Dealing with telling a mother that her child has a life-threatening deformity takes a very special kind and caring person. But it was a real pleasure to see normal newborns in the nursery and the joy it brought to their parents. I guess that was another little seed that was being planted in me to grow later on. So we learned that most babies are born healthy and their care just involved checking them out to assure their parents that they were indeed well.
As with general medicine, the majority of our time was spent on the pediatric wards. But unlike the medical rotation, there was very little interviewing of the patients themselves. Of course we did have to question the parents for as much information as they could supply. Many times, unfortunately, because of the area we were in I first was exposed to a family that usually was lacking a father figure and, sometimes, a mother as well. Several children were being raised by their grandmother for one reason or another. Many of the mothers had children by various men and they were left alone to care for them. Some did a tremendous job and there were some that I thought should have never been able or allowed to have a child. Child abuse is a particularly offensive crime and it, unfortunately, does exist. From children being beaten, molested, to out right neglected, we saw it all. Many times I went home literally sick from what I had observed that day. How could anyone be so cruel as to harm one of these defenseless little individuals? Yet it is a fact of life that sort of behavior exists and it is heartbreaking to see it happen. Hopefully you can better understand what it takes to be able to call yourself a doctor. It is more than I certainly thought. I had no idea what it would take and to what I would be exposed. The tremendous highs and lows are part of everyday life for a physician. Most are very good at dealing with them but there are a few who are just head and shoulders above the rest of us. I was about to meet one of these unique individuals.
One of our professors was a man who I have the utmost respect for of all my teachers. Just the way he would gently talk to the children was a model I try to employ with all my patients. Dr. Theodore Kushnick was a man who really loved his work. An excellent teacher and an excellent physician are a rare breed but that man had it all. Once again we were initially frightened of him because he was very demanding, but he taught us that our patients deserved our very best efforts and, by his example, he showed us what it takes to do that. He had a tremendous amount of knowledge and we were all amazed at how he could listen to our presentations and come up with a diagnosis list of at least 50 disease possibilities. He particularly enjoyed coming up with extremely rare diagnoses because he taught us that we had to think of those conditions also when evaluating a patient. He would remind us that common things happen commonly, but we must always be prepared for the uncommon problems also. As I said before, it is particularly difficult to care for children because of the lack of communication but he made it look so easy. He would teach us how to look for the subtle clues that a child would unknowingly give as to what was wrong with them and he was a master at it. Just the way a child would hold or position themselves could be the clue needed to determine what was wrong. With his large and gentle hands he would hold a screaming child and calm him down like only a mother could. What a great talent this man had and we were all extremely fortunate to have been taught by him. I am sure that almost all of my classmates have the same fond memories of this great man. By the way I am sure he was the inspiration that one of my classmates had to later go on to become one of the world’s experts on caring for children suffering from AIDS. Dr. James Oleski was a pioneer in the treatment of children with AIDS and was a fellow classmate of mine..
My pediatric rotation also brought me one of my saddest moments in medical school. One of the children I had the privilege of caring for was a beautiful blonde haired, blue-eyed girl by the name of Christine. She was 12 years old when I met her and she had just been diagnosed with acute lymphocytic leukemia. In the three months that I knew her she taught me what it was like for a child to know that she was dying. She faced her fate with tremendous courage and fought with all her might to survive. She endured all the horrible effects of chemotherapy with a smile and often tried to cheer me up by asking "and how are you today, Doctor?" She was a private patient of one of our prominent pediatricians who was an expert in childhood cancers. Christine was an only child like I was and her parents were devastated when they learned that their sweet beautiful child had cancer. But, unfortunately, her cancer was so far advanced when it was diagnosed that there was not much hope from the outset. I learned a lot by helping to care for her and I think of her often even to this day. As much as I tried to give her hope that she would be cured, I could tell she knew that she was losing her battle. Sometimes physicians give strength to their patients to deal with their diseases and sometimes, like with Christine, patients give strength to their physicians to deal with the fact that we cannot cure everyone. I looked forward to seeing her every day, but I hated to see what was happening to her. She endured many painful and experimental treatments with a smile and never once complained. One day her parents had given her a cute pink hat to wear because she had lost most of her hair. I remember going in to see her that day and she jumped up in her bed, removed her hat and asked me "am I still cute even though I've lost all my hair, Dr. Pieter?" I did all I could not to break down in front of her. She was teaching me in her own sweet way to be strong for the patients that I would inevitably lose in the future. Some nights I would stay with her after her parents went home and we would watch TV together until she went to sleep. I did not want her to be alone as the end drew near. I will never forget the night she told me that she knew she was going to die but that it was okay. “Thank you and all the other doctors” she said for taking care of me. What tremendous courage and insight this young girl had as her life was slowly slipping away. As Christine grew weaker, she lapsed into a coma one day and I prayed that her suffering would soon be over. Then, finally, a few days later she mercifully passed away. I had lost my first patient and I was devastated. I left the building crying and it continued for days afterwards. Why could we not help that beautiful child? I was disappointed in myself and angry at the medical profession that we were not able to save her. After her death, I had hoped that someday I would have a daughter of my own and I wanted to name her Christine in her memory. I was to have four sons but she is still in my thoughts and prayers. Because I knew that I would never be able to care for sick children again like Christine, being a pediatrician was also removed from my choice of specialties. The list of specialties that I was interested in was getting smaller. But, happily, we next moved on to my favorite rotation, general surgery.
General surgery was to be my best rotation. I had looked forward to it for quite a while and I was very excited that I was finally there. What would it actually be like to stand over a human being and be faced with having that person's life or death in my hands? It is an awesome responsibility, but one that surgeons do not dwell on. Through the course of our training repetition was the best teacher, but I have never looked upon any operation as routine. Most of us strive not to think of the next person being operated on as just another hysterectomy or gallbladder operation. Once a surgeon makes the initial incision, however, it is like his eyes have blinders on and he focuses on the anatomy and whatever surgical procedure that he is doing. But even to this day prior to any operation I try to remind myself that it is a human being that I am taking care of and, occasionally, it is someone I have known for many years. Once we enter an operating room, however, there is a transformation that takes place into someone who is performing a special skill that has taken years to hone and develop. An operating room or OR is a unique place and to me it is often like entering another world where the outside is, for a period of time, completely shut out. It requires the utmost of concentration sometimes for hours on end, yet it has never felt routine or like work to me. But I do realize that it is not only me or the surgeon who are important, it is a team effort. Yes, the surgeon is the team leader and is ultimately responsible for the success or failure of that operation. But as we will see later on when we discuss malpractice, many times the outcome of an operation can be influenced by any member of the team, even one not physically present in the operating room. The support members of the hospital staff are also very important and professional people who contribute to the overall outcome in our patient’s care. Oh, and yes, there is one other that we must include on the team. I am a Christian and on the way to the hospital I often ask God to guide my hands and give me the knowledge and skill to help me care for my patients.
So after all the waiting and dreaming I had finally arrived at the door of the operating room. Well, not quite, because I was about to find out that, as a medical student, I might not even make it into the operating room. I was the lowest person on the totem pole, so I was about to find out that a lot goes on before a patient goes to the OR. My first rotation in surgery was at a Veterans Administration or VA hospital. Again, as the junior member of the team, I had to perform all the tasks necessary prior to surgery. Even when I did get into the operating room, I was so far away from the patient often I could barely see what was going on. But I was in there and I was thrilled and awestruck. The amount of time that would be spent in learning the ropes was tremendous but very necessary and it would require years of exposure with slowly increasing levels of responsibility to get to the point where I could actually call myself a surgeon. So my hours were again filled with performing lab tests, starting IV’s, and doing H & P’s until the early hours of the morning and beyond. We slowly were exposed to different areas of the surgical specialty. It was difficult just learning all the different areas that we needed to be exposed to. From general surgery we went on to different areas like Neurosurgery, Ear, Nose, and Throat, Thoracic surgery, Ophthalmology, Urology, Plastic Surgery, and Orthopedics. All of which we looked upon as just getting a little taste of and feel for what different areas would be available if we chose to become a surgeon. Yet there were many of us who had already found out or were about to find out that maybe this was not what we wanted to do. But our teachers did a tremendous job of exposing us to the world of surgery and the tremendous opportunities that lie within it. I must say I enjoyed all of the subspecialties of surgery and I was beginning to realize that a lot of the final choices that we would eventually make for our careers would be influenced by the many doctors we would work with. How well they exposed us to their specialty and what interaction they had with us would be key to our knowledge and understanding of it. If I liked a particular doctor, I certainly found myself getting much more out of that rotation. To all those who have helped me in that journey, I thank them very much for the time and devotion they gave to my education. They showed us the love and devotion they had for their specialty. So as you can see, we were just getting a little taste of each of these subspecialties and it was so important to get even a brief look at each one for us to begin to make our final decisions for our careers. Although I really did not get to do much at the operating table that year, I knew it was what I wanted to do and I spent as much time as I could in and around the OR. It was beginning to feel like my new home and I couldn't get enough of it. I wanted to be there more than anywhere else and I was prepared to spend the many years of training that would be necessary to make me a surgeon.
My next rotation was obstetrics and gynecology, which unbeknownst to me at that time would be my ultimate choice of specialties. I thought that I had pretty much decided to be a surgeon early in my training. My obstetrical rotation at St. Elizabeth's Hospital in Elizabeth, New Jersey would change all that. The medical school had developed a program with some local hospitals to have its students branch out and see what the private practice of medicine was all about. It also was a good way to have our students exposed to as much as possible instead of all of us being trained in one place and competing with each other for the work. We also worked in the free clinics at those hospitals. That was where I was introduced to the Labor and Delivery suite. I knew right away what a special place that would become in my life. I would even meet my future wife on the L & D floor at a different hospital years later. After we were introduced to the nursing staff and several obstetricians it was time to learn what the birth process was all about. My first night on call proved to be quite a memorable experience. That night I retired to the doctors’ lounge and selected the lower portion of a bunk bed to sleep in. I was told I would be called before the next delivery so I could observe. Well, I am told that I did not respond to several phone calls, so the head nurse opened the door and screamed at the top of her lungs "DELIVERY! GET UP!!!" Aroused from a deep sleep, I proceeded to jump up and hit my head on the bed above me and collapsed back down unconscious. As I woke up several people were standing over me asking if I was all right. It was an inauspicious start to my Obstetrical career, but I never missed another delivery again, at least because I was sleeping. Obstetricians have to have a rare ability of being able to wake up from a dead sleep and perform at their best. That I assure you, is an acquired talent and one that I had to develop after my embarrassing start. But I did and, to this day, I can wake up abruptly in the middle of the night and be wide awake almost immediately. There are some obstetricians who are not capable of doing that, worse yet, don't do it well and I have seen them struggle to cope with it in their own ways. I obviously had no idea that so many babies were born in the middle of the night, but I was about to learn a lot of things concerning childbirth that a naive young male from the suburbs had no idea about.
So with lesson one, how to wake up in the middle of the night, behind me, I began to learn about the process of labor and delivery. I would follow the nurses around as they went from room to room observing what was happening. Listening to some women crying out in pain was shocking at first, but I quickly learned how satisfying it was to help them. At that time nurses had to frequently monitor the baby’s heartbeat with a special stethoscope in order to detect any abnormalities or signs that might indicate a baby was in trouble. That was before the advent of the fetal monitor, a device used to continually listen and record the heartbeat of the baby while in the mother’s womb. I was beginning to see that it took a very specially-trained nurse to be able to do that and do it well. So one of the first things I learned was that nurses were very important in that specialty. I learned a lot from them throughout my career. I learned that an obstetrician had to assess a nurse’s judgment and then develop a sense of trust in him/her. There were nurses who you knew were very good and you better listen to them when they called you with a problem. There were also, only a few, that were known as alarmists and if they were on, you knew it was going to be a long night with little sleep. Speaking of sleep, that is another trait that obstetricians must have and that is to be able to work with only a nap here and there or no sleep at all. Being up all night and being able to function at work the next day became the norm for me. This was so important that, as my obstetric career drew to a close, it was one of the first things that told me it was time to quit. I never lost the interest and love of delivering babies, I just couldn't physically do it any longer. Fortunately that took 35 wonderful years and the delivery of almost 4,000 babies to happen.
The first time I delivered a baby was such an exciting experience and one that I continued to be amazed and excited about throughout my entire career. Late one night the obstetrician I was assisting said okay you are going to deliver this baby. As the mother pushed with all her might the baby's head appeared and I grasped it tightly. There I was holding this beautiful creature in my hands for the first time. To be present and watch a mother's eyes light up upon seeing her child for the first time is a wonderful thing to share. It is, for me, the purest expression of love that I know. So once I was bitten by the obstetrical bug, what about my dreams of becoming a surgeon? Well, fortunately for me, obstetrics is only one part of this specialty. The other is gynecology and that involved doing female pelvic surgery. I could not have drawn it up any better. It gave me a chance to do both of the things that really interested me in medicine. So I had now made the decision of what specialty I was going to pursue and I began to make plans of how I would accomplish this goal.
So as that difficult but rewarding year drew to a close, we prepared for our final year of medical school. We had learned a tremendous amount of information, but we also realized there was a lot more to know. I looked forward to my last year with great eagerness, but I also knew that I only had one more year to prepare myself to be a physician and I was determined to make the most of it. Instead of dreading what we had gone through I was seeing the big picture much more clearly. I was beginning to appreciate that the hard work of the prior years were all beginning to come together to prepare us for the next big step in our medical careers. We also had another great milestone in the third year and that was that we did not lose one student that year. Everyone who began it completed it and it was a nice feeling for a change. We began to walk around with a little more sense of belonging and maybe some cockiness, but that was okay because I felt that we had earned it. Once graduation was completed for the seniors, we were the big shots on the block and it felt great. I did miss being with my former classmates for graduation but, by then I was really emotionally tied to my new friends and I felt like I was really a member of the class of 1970. We had been through a lot together but, like before, it was always tempered with the knowledge that we still had a long way to go.
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